Forms

Referral Form

Print the Referral Form, fill it out, and send it to us via fax, mail, or email.
Referral Form

 

Statement of Informed Consent

Review the Statement of Informed Consent and let us know if you have any questions. We cannot treat you if you do not sign this form. You will be asked to sign this form when you arrive for your appointment.
Statement of Informed Consent

 

HIPAA Notice

This notice describes how psychological and medical information about you may be used and disclosed, and how you can get access to this information. You will be asked to acknowledge that you have received our notice of privacy. You may print out our HIPAA notice and keep a copy for your records.
HIPAA Notice

 

Patient Registration

Please complete this form prior to your scheduled appointment. The completed form can be mailed or faxed to our office.
Patient Registration

 

Release of Information

If you would like information about your treatment to be released to another party you will need to complete and sign a Release of Information Form. There are a few circumstances in which we may be bound by law to release information without your written consent. These circumstances will be discussed with you at your scheduled appointment.
Release of Information

Please note, in most cases, we are prohibited by law from disclosing raw psychological and neuropsychological test data and test materials to anyone other than a licensed psychologist qualified to interpret such data.

 

Electronic Communication Policy

This policy is to provide guidelines regarding the use of electronic modes of communication with your provider during your treatment.
Electronic Communication Policy

 

Statement of Financial Responsibility

The Statement of Financial Responsiblity details your responsibilities regarding billing and payment for services.
Statement of Financial Responsibility

 

Get In Touch:

If you have any questions, would like to refer a patient, or to set up an appointment please call or send us an email.

Phone number: 541-306-6456
Fax number: 541-647-1580
Email: info@orneuropsych.com